Have You Been Misdiagnosed?

In an interview with Jane Cartwright, a Mood Disorder Support Group of New York (MDSG) Newsletter contributor,
Dr. Gianni Faedda discusses common causes of misdiagnosis of Bipolar Disorder.br>
The number of people suffering from manic depression who are misdiagnosed with depression is staggering, according to Gianni Faedda, M.D., who will speak to MDSG on the subject December 3rd, 2001.

Are you one of them? Have you been told you suffer from depression alone, but you don't seem to get better with antidepressants? Is your depression worse even though you're on antidepressants? Does your depression recur? Come listen to a renowned researcher and practicing psychiatrist describe bipolar symptoms many physicians miss and why.

More than half of those with bipolar illness are not getting proper treatment with mood stabilizers, because their doctors are not picking up subtle signs of elevated or shifting mood, according to Dr. Faedda. Patients with manic-depressive illness (MDI) often seek help when they're suffering from severe depression, he added, and without a thorough history of their illness or proper attention given to family history, many doctors misdiagnose major depression and prescribe antidepressants.

But the clinical picture may be more complicated: the patient may be experiencing the depressed phase of manic depression. In these cases, taking antidepressants at all, or without a mood stabilizer, may make the illness far worse, said Dr. Faedda. And such a diagnostic mistake can be costly: the patient may lose his or her career, family relationships, friends and way of life.

"The most common form of misdiagnosed MDI is probably the group of conditions that manifests predominantly with depressive symptoms," said Dr. Faedda. "Those in which the up swing (or the manic phase of the cycle) is very subtle-perhaps even milder than what is described as hypomania (a milder form of mania)."

"These are forms that present basically as recurrent depressive conditions where there might be very short-lived, apparently 'well' intervals between depressions," said Dr. Faedda. "We have shown that these pseudo-unipolar forms can be highly recurrent, can sometimes have a seasonal course or a very early age of onset . . . Often these are initially treated with antidepressants, but turn out, in large numbers, to be what we call treatment-refractory depression (hard-to-treat depression)."

In fact, misdiagnosis may be more of a problem than we realize. Dr. Faedda cites a study in which 250 patients with major depression were evaluated. After the initial interview, 22 percent were re-diagnosed bipolar. But with further and more sophisticated evaluation, the number of bipolar patients jumped to 40 percent. "When a patient presents with depression, nobody poses the question, 'Is this the depressive phase of manic depression?,'" said Dr. Faedda. "Almost everybody starts with a diagnosis of depression as if manic-depressive illness were a rare disease that only presents with mania. Nothing could be further from the truth."

Sometimes bipolar depression "responds almost miraculously" to antidepressants, he noted, but this may be short lived. Or the depression improves but then switches to hypomania and increased cycling.

"Patients may sometimes enter what we call depressive, mixed states (symptoms of both depression and mania) ", said Dr. Faedda. "These look like severe or agitated depression. There are a lot of excitatory symptoms such as anxiety, racing thoughts, restlessness and insomnia. These forms of illness-instead of improving with antidepressants-actually get worse."

While the current estimate of the prevalence of bipolar disorder in the population is 1 percent-the same as schizophrenia-it may, in fact, be far more common; it may be as high as 5 to 10 percent, according to Dr. Faedda.

What can be done to avoid misdiagnosis?

'The first issue is education," he said. "We need to provide the general public with the means to assess their behavior, to watch for changes in sleep patterns, changes in mental functioning, changes in physical activity and to urge them to report these to their doctor."

Many people may not know that "one of the most common features of manic-depressive illness is the patients' tendency to self-medicate with alcohol or other substances," he said. "There is often abuse of both sedatives and stimulants. You see this with about 50 percent of people suffering from manic-depressive illness."

"A collaborative effort between the doctor, the patient and their families is important in order to reach an accurate diagnosis and to implement a successful course of treatment." Dr. Faedda said.

"Before a diagnosis is made, a careful family history must be taken. This is a hereditary condition. I ask all my patients if they or anyone in their family have had an unusual work history such as a frequent change of jobs, or frequent moves from place to place, or difficulty staying in a relationship or financial difficulties such as accumulated debt. I inquire about substance abuse, gambling, violent or criminal behavior."

Dr. Faedda warned physicians not to prescribe antidepressants indiscriminately. "I don't think anybody with a family history of manic-depressive illness or with symptoms suggestive of a recurrent illness should be treated with antidepressants alone," he said, "not without careful consideration of clinical features suggestive of a mild, subtle or atypical form of manic-depressive illness. If one is not careful, a depression can be helped but at the cost of destabilizing the illness."

He thinks the Diagnostic Statistical Manual IV, the instrument most physicians use to diagnose psychiatric disorders, is too limited in its definition of bipolar disorder. "It is essentially a research instrument for identifying patients with classical symptoms of the illness for research protocols," he said, "not a way of identifying those who may benefit from mood-stabilizers."

". . . There are many (mood-disorder) conditions that fall on a continuum," he said. "Certain forms only have depressive symptoms, other forms only have manic symptoms. There are forms that are highly recurrent, and there are forms that only have one or two episodes over a lifetime; there are forms that are rapid cycling, with very short-lived episodes; others tend to be almost chronic or chronic; there are forms with psychosis and others without."

"Before we go hairsplitting and defining subtypes, we have to define those conditions that are likely to respond to mood stabilizers. The real issue is guaranteeing that those who can benefit from mood stabilizers are given a proper chance to see if they'll respond to them-as opposed to putting everyone on antidepressants- and then going back and treating antidepressant-induced hypomanic or manic symptoms.

"The word bipolar, in fact, may be a misnomer, because there are forms of depression or so-called depression that are responsive to medications that help people with manic depression. I think it'a tragedy that physicians are withholding mood stabilizers from patients only because they don't meet man-made criteria, now being considered almost like a dogma."

Dr. Faedda, who is researching the course of manic depressive illness in children and adults, estimates 50 percent of bipolar disorder patients had symptoms as early as childhood.

What symptoms should we look for in kids?

"Any pathology that affects mood or activity, including symptoms of attention-deficit disorder or aggressive behavior," he said. A family history of any mood, anxiety or substance abuse disorder is a red flag. "Children as young as four may think about suicide," he said, "and make attempts when they reach their teens. With as many as 20 percent of untreated, bipolar-disorder patients committing suicide, this is far from a benign condition."